Scientific paperPitfalls in the management of penetrating chest trauma
Abstract
A prospective study designed specifically to analyze errors in management and iatrogenic complications was conducted on 234 consecutive patients with penetrating chest trauma. Eleven percent of penetrating pleural injuries were incorrectly diagnosed on initial physical and radiologic examination, but this led to wrong management decisions in only 4 percent. Decisions regarding intercostal tube drainage were particularly inaccurate when emergency intubation was required prior to chest radiography. Atypical clinical features of penetrating cardiac injuries caused delay in diagnosis and thoracotomy in 3 of 14 patients. Only two of four mediastinal vascular injuries were recognized on initial examination. Transdiaphragmatic injuries were initially missed in 5 of 14 patients. This resulted in management errors and delay in these patients. Awareness of atypical presentations and circumstances in which misjudgments and wrong decisions are prone to occur should help to avoid pitfalls and reduce mortality from penetrating chest trauma.
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Cited by (44)
In the setting of the hypovolaemic patient with a thoraco-abdominal stab wound and potential injuries in both the chest and abdomen, deciding which cavity to explore first may be difficult. Opening the incorrect body cavity can delay control of tamponade or haemorrhage and exacerbate hypothermia and fluid shifts. This situation has been described as one of double jeopardy.
All stab victims from July 2007 to July 2009 requiring a thoracotomy and laparotomy at the same operation were identified from a database. Demographics, site and nature of injuries, admission observations and investigations as well as operative sequence were recorded. Correct sequencing was defined as first opening the cavity with most lethal injury. Incorrect sequencing was defined as opening a cavity and finding either no injury or an injury of less severity than a simultaneous injury in the unopened cavity. The primary outcome was survival or death.
Sixteen stab victims underwent thoracotomy and laparotomy during the same operation. All were male with an age range of 18–40 (mean/median 27). Median systolic blood pressure on presentation was 90 mm Hg. (quartile range 80–90 mm Hg). Median base excess was −6.5 (quartile range −12 to −2.2). All the deaths were the result of cardiac injuries. Incorrect sequencing occurred in four patients (25%). In this group there were four negative abdominal explorations prior to thoracotomy with two deaths. There was one death in the correct sequencing group.
Incorrect sequencing in stab victims who require both thoracotomy and laparotomy at the same sitting is associated with a high mortality. This is especially true when the abdomen is incorrectly entered first whilst the life threatening pathology is in the chest. Clinical signs may be confusing, leading to incorrect sequencing of exploration. The common causes for confusion include failure to appreciate that cardiac tamponade does not present with bleeding and difficulty in assessing peritonism in an unstable patient with multiple stab wounds. In the setting of the unstable patient with stab wounds and suspected dual cavity injuries the chest should be opened first followed by the abdomen.
The spectrum of diaphragmatic injury in a busy metropolitan surgical service
2009, InjuryCitation Excerpt :There is however the potential for error in these patients. Chest X-rays are confusing to inexperienced clinicians and may be misinterpreted and inappropriately acted upon10,21 (Fig. 3). We had a high incidence of inappropriate cannulation in our series of patients presenting with acute herniation.
The diaphragm may be injured by penetrating or blunt trauma. Diaphragmatic breach without visceral injury or herniation may be difficult to detect due to a paucity of clinical signs and herniation may be misdiagnosed following the erroneous interpretation of chest radiology. If not recognized there is a considerable risk of late morbidity and mortality. This prospective study reviews our experience with diaphragmatic injury in a busy general surgical service with a large trauma component.
A trauma database is maintained by the general surgical service of the Pietermaritzburg metropolitan complex. All patients who sustained a diaphragmatic injury between September 2006 and September 2007 were included in this study.
A total of 54 patients with diaphragmatic injury were treated in the period under review. There were three broad groups, namely those with simple breach of the diaphragm (37), acute diaphragmatic hernias (11) and chronic diaphragmatic hernias (6). Thirty-seven patients had a diaphragmatic breach confirmed at either laparotomy or laparoscopy. The mechanisms of injury were stab (24), gunshot wound (10), blunt trauma (2), and shotgun (1). There were seven (19%) deaths. In 19 asymptomatic patients laparoscopy was performed because of the presence of a stab wound to the left thoraco-abdominal region. Five (38%) of these patients were shown to have a diaphragmatic breach at laparoscopy. Eleven patients presented with an acute diaphragmatic hernia. The mechanisms of injury were stab (5), blunt trauma (5), and gunshot (1). The hernia contents were stomach (10), colon (1), and spleen (2). The operative approach was a laparotomy in 10 patients and a thoraco-laparotomy in one. Six patients presented with a chronic diaphragmatic hernia of longer than six months duration. The mechanisms of injury were stab (4), blunt trauma (1) and gunshot wound (1). The average delay from injury to presentation was 3.5 years. The contents were colon (3) and stomach (3). All were managed by laparotomy.
If there is an established indication for laparotomy diaphragmatic breach is usually recognized and dealt with appropriately although failure to follow standard principles may result in the injury being overlooked. Isolated diaphragmatic injury without associated visceral damage cannot be diagnosed clinically or radiologically. Direct video-endoscopic inspection confirms or excludes the diagnosis and has a high pick up rate. Diaphragmatic herniation can present acutely after trauma or at a time remote from the original injury. Acute diaphragmatic injury may be confused with other pathologies and there is a risk of inappropriate intervention. Most diaphragmatic hernias can be repaired via laparotomy.
Pulmonary trauma emergency department evaluation and management
2003, Emergency Medicine Clinics of North AmericaPenetrating chest injuries in the firearm era
2001, InjuryBackground: firearm wounds of the chest are now common at our institution. The management algorithm for firearm wounds has not been evaluated for this mode of injury. Methods: records of all patients with penetrating chest injuries admitted to an urban tertiary hospital over 1 year were retrieved and analysed. Results: there were 473 stab and 116 firearm wounds. In comparison to stab injuries firearm wounds had significantly more normal X-rays (14 vs. 5%), fewer pneumothoraces (15 vs. 37%), and more contusions (43 vs. 2%). The frequency of haemothoraces (34 vs. 23%) and haemopneumothoraces (36 vs. 35%) was similar in both groups. Stabbing caused all the 18 cardiac injuries. Associated abdominal injuries occurred in 8% of stab and 34% of firearm injuries. Pneumothoraces due to firearms were uncommon and rarely required drainage. More pneumothoraces were treated nonoperatively among firearm injuries in contrast to stabbing injuries where the opposite applied. The management of haemothorax and haemopneumothorax was similar in both groups that fulfilled the criteria for drainage. The rate of ICU admission was higher and the hospital-stay longer following firearm injuries. Fifty-nine patients died (10% of the total), 33 (28%) from the firearm injuries and 26 (6%) from stab-wounds. Early deaths were 1 and 3% for stabs and firearms, respectively. Conclusions: patients with firearm injuries reaching hospital suffered three times higher mortality and a longer ICU and hospital stay than those with stab injuries. However, early mortality was similar for both modes of injury and validates the continued application of the stab wound derived management algorithm to all modes of injury.
Echocardiography in thoracic trauma
1998, Emergency Medicine Clinics of North AmericaEchocardiography (echo) is a well-known diagnostic technique used in the workup of both blunt and penetrating thoracic trauma. A skilled cardiac sonographer can obtain comprehensive anatomic and functional information assessing the heart, but even in some Level I trauma centers, cardiologists or trained echocardiographers are not readily available 24 hours a day.1, 21, 39 In the initial evaluation of the acutely injured patient, however, a focused, limited echo examination can provide the critical information the clinician needs to make decisions such as immediate surgery versus further diagnostic workup. For this reason, as stated previously, the use of focused bedside ultrasonography by emergency physicians and trauma surgeons is rapidly increasing in North America. The focused examination cannot replace formal echocardiography in the amount and quality of information obtained; its value lies in the fact that it can provide time-critical information when and where it is needed, 24 hours a day in the emergency department (ED), where acutely injured patients present. Current use of this technique by the trauma clinician centers on the identification of traumatic pericardial effusion (hemopericardium).
The detection of pericardial effusion (PE) in victims of chest trauma is one of the most critical applications of emergency bedside ultrasonography. The presence of PE may indicate significant cardiac injury and impending cardiac tamponade, so that its early detection immediately impacts patient management decisions and may decrease the time to definitive surgical care, thus optimizing chances for good outcomes. Emergency physicians and trauma surgeons who initially evaluate these patients are ideally positioned to make this diagnosis rapidly. Clinical signs and symptoms of PE and cardiac tamponade, however, are notoriously unreliable.15 It is therefore essential that these clinicians be familiar with the indications and limitations of echocardiography and ideally be able to perform a focused bedside two-dimensional echocardiographic examination to detect pericardial effusion.23
Two-dimensional echocardiography (or 2-D echo) is the formal term for real-time ultrasound examination of the heart.18 The most common and readily available technique is the transthoracic echocardiography (TTE). The TTE is performed by placing an ultrasound transducer (2.0 to 2.5 MHz for thick-chested adults, 3.5 MHz for normal adults, and 5 MHz for children) on the surface of the thorax overlying the standard imaging windows (parasternal, apical, and subcostal) to the heart (Figs. 1, 2, and 3).18, 24 TTE has been used successfully by emergency physicians and trauma surgeons to detect PE in trauma victims.33, 36, 43, 46 More recently, transesophageal echocardiography (TEE) has emerged as a technique useful for early detection of both cardiac and aortic injuries. TEE is a more invasive approach that requires a higher level of expertise and personnel and thus far is performed mainly by cardiologists. TEE can be performed in the resuscitation area to make critical diagnoses rapidly, so that emergency physicians and trauma surgeons should be familiar with this technique and work with cardiologists to ensure immediate availability of this important diagnostic modality.32
The physiological variables of oxygen saturation, blood pressure and pulse rate were compared in the pre-hospital phase and on arrival at hospital in a group of 63 patients with severe chest injury. Eighty-nine pre-hospital thoracic drainage procedures were carried out. Pre-hospital Advanced Trauma Life Support (ATLS) was associated with a significant improvement in all three variables. Median oxygen saturation increased by 17 per cent (P<0.001), median blood pressure increased from 90 to 120 mmHg (P<0.001) and median pulse rate decreased from 125 to 105 (P<0.001). Pre-hospital intervention is indicated for tension pneumothorax, and contraindicated for haemothorax without respiratory compromise. In other situations further evidence is required, and standard ATLS protocols should be used until this is available.
- 1
From the Department of Surgery, University of Natal Medical School, Durban, South Africa.